An independent committee appointed to review how the World Health Organization (WHO) performed during West Africa's Ebola outbreak found several management and cultural problems that slowed the response, but it also said flaws in the International Health Regulations (IHRs) also posed tough obstacles.
One of the group's main requests going forward was for a way to signal an alert earlier, aside from declaring a full-blown public health emergency, which often takes months and can be bogged down by political concerns.
Also today a WHO emergency committee for Ebola decided, after meeting for the sixth time since the outbreak began, that the event is still a public health emergency and that its earlier recommendations be extended.
Earlier findings guided WHA actions
WHO Secretary-General Margaret Chan, MD, MPH, in early March commissioned the independent expert panel to review its response to the Ebola epidemic. In 2010 it took a similar step in asking an outside group to review its response to the 2009 H1N1 influenza pandemic.
The six-member panel was led by Dame Barbara Stocking, who managed major humanitarian responses while she led Oxfam GB from 2001 through 2013. She is currently president of Murray Edwards College at the University of Cambridge.
In May the group released its initial findings ahead of the World Health Assembly (WHA), which approved a set of reforms proposed by the WHO's executive board for improving the way it responds to public health emergencies. They included plans for establishing clear command and control mechanisms across all WHO levels, an all-hazards emergency program, and a $100 million contingency fund to pay for initial field operations in emergency settings.
The WHA also asked the WHO to set up a group to review how the IHRs performed during the Ebola outbreak, having asked for a similar evaluation after the 2009 H1N1 pandemic.
Full recommendations take broader view
In its initial report in May, the independent group made 12 observations but said it would broaden its focus to help the WHO respond to the next public crisis. The group met three times in Geneva and traveled to Guinea, Liberia, and Sierra Leone as part of its fact finding and analysis.
In the 28-page report it released today, the panel made 85 observations and 21 recommendations.
At a media telebriefing today, Stocking called the report a defining moment for the WHO and member states. She added that the group is pleased that the WHA similarly concluded that the WHO's function during international health emergencies needs to change.
In its report, the panel said the Ebola crisis revealed that many member states haven't implemented required core capacities as outlined in the IHRs, especially regarding surveillance, and that nearly a quarter of the countries violated the regulations by instituting travel bans and other measures that interfered with the response.
Also, the IHR process for declaring a Public Health Emergency of International Concern (PHEIC) caused significant and unjustifiable delays in raising the distress signal for the world to take action, the team found.
The team suggested that an intermediate alert level be added to the IHR. "The world needs a better understanding early of a growing concern," she said.
It suggested that the IHR review committee consider incentives, such as insurance to protect against economic effects, for countries to notify the WHO about possible health emergencies. The panel also suggested sanctions for countries that take measures beyond WHO recommendations that interfere with trade or travel during health crises.
The committee said the WHO doesn't have the capacity or organizational culture to deliver adequate outbreak management. It said solid funding isn't in place to fund WHO emergency response activities and pointed out that the WHA at its recent meeting opted not to recommend an increase in assessed contributions from countries.
Member states need to show the political will to assist WHO with the resources to respond to health emergencies, and countries and their partners should immediately contribute to the $100 million contingency fund to support early outbreak response, the report said.
One of the WHO's main problems during the response was that it struggled to incorporate outbreak control and humanitarian activities, the panel found. It suggested that the WHO establish a Center for Emergency Preparedness and Response, with an independent board to oversee its work. Other key recommendations are that the WHO coordinate its emergency levels and grades with that of humanitarian groups.
Stocking said that during the panel's investigation it became clear that humanitarian groups and even some health ministries didn't understand the risk of Ebola, and that it would be helpful if all groups had a shared understanding of health threats.
Casting its assessment beyond the WHO, the group said some health emergencies need high-level United Nations (UN) engagement to activate the world community to come forward to assist. It suggested that, in the future, rather than appoint a full UN mission, the WHO should appoint a special director-general envoy.
Establishing the UN Mission for Ebola Emergency Response (UNMEER), the first for a PHEIC, didn't work well, because it is difficult to establish a new system in the middle of a crisis, Stocking said. Also, she noted that humanitarian groups are used to working with the UN's existing health cluster system.
In a statement today, the WHO said it welcomed the independent assessment panel's report and announced that Chan will convene a committee to review the IHRs in August. The agency said it will consider the panel's recommendations, including its suggestion to add an intermediate alert level, short of declaring a full PHEIC.
Also the WHO said it is already moving forward on some of the recommended steps, including developing a global health emergency workforce and contingency fund to ensure that the staffing and financial resources are needed to respond more quickly in future outbreaks.
The WHO agreed with the panel's recommendation that its health emergency systems needs better integration with humanitarian response systems, including closer coordination of humanitarian emergency grading and IHR emergency declarations.
"The current Ebola outbreak is still ongoing, and improved methods of working are incorporated into the response as they are developed," it said. "But it will take many more months of continued hard work to end the outbreak and to prevent it from spreading to other countries."
Ebola emergency still in effect
Meanwhile, the emergency committee appointed to advise the WHO met for the sixth time last week to review the latest developments—including the detection of three recent cases in Liberia—and announced today that the outbreak still poses a PHEIC as defined under the IHR.
Though some improvements have occurred, a number of countries still have inappropriate travel measures in place and some airlines haven't resumed flights to the affected countries, the group said in a statement today.
The committee also recommended extending the temporary steps it recommended several months ago to help curb the outbreak.
Since its last meeting on Apr 9, the number of cases has decreased, but progress has stalled over the past 5 weeks. The committee said it was concerned about the new cases in Liberia and urged preparedness activities in border countries to continue.
It also welcomed a new "phase 3" response phase to identify, trace, and interrupt all Ebola transmission chains.
WHO emergency committees typically meet every 3 months or earlier, based on outbreak developments.
Ebola recovery on the agenda
In advance of a major conference to address the recovery needs of Ebola-hit countries, the WHO said yesterday that rebuilding the countries' health systems is a critical priority.
The meeting, convened by UN Secretary-General Ban Ki-moon, takes place in New York City on Jul 9 and Jul 10 and is designed to draw funding stakeholders and the affected countries together to garner attention to recovery needs and to target strategies.
In a statement from the WHO's Regional Office for Africa, its director, Matshidiso Moeti, MD, said health systems in Guinea, Liberia, and Sierra Leone are severely underfunded. The office warned that the countries are still working to get cases to zero, but when they do, staying at that level won't be possible unless rebuilding their health systems starts now.
The WHO said Guinea still needs to raise $386.5 million, Liberia $169.7 million, and Sierra Leone $140 million through 2017 to meet their individual needs.
Jul 7 WHO independent panel interim assessment
Jul 7 WHO response to assessment
Jun 6 WHO statement on Ebola recovery
Ebola recovery conference background